PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: The Sanitizer in the recreation/activity room is not operational and PICs are restricted to participate in activities involving the kitchen.
Corrective Action(s): Please ensure that all equipment for the PICs use are maintained in a good state of repair.
Date to be Corrected: February 15, 2022
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A review of the medication administration records (MAR) found that some staff were not signing the MAR sheets appropriately per shift.
2/7 PRN medications administered in January did not have the effectiveness of the PRN documented as per the policy and 3/7 MAR sheets had missing signatures for the scheduled medications. This was brought to the attention of the staff person assisting with the medication room inspection.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: February 15, 2022
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: 2/5 PICs had restraints used for preventative measures to ensure PIC’s safety but no PIC/representative consents were on file.
Corrective Action(s): Please ensure that the agreement(s) for the use of restraint is signed by the PIC or the relative who is closest to and involved in the life of the person in care.
Date to be Corrected: February 15, 2022
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: No Physician or Nurse practitioner approval is in place for the 2/5 PICs who use restraints as preventative measures to ensure PIC’s safety.
Corrective Action(s): Ensure that for PIC’s who need on-going restraint have the agreement for the use of restraint signed by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Date to be Corrected: February 15, 2022
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The following were observed:
1). The daily temperature log for the PICs fridge was not maintained for the month of January 2022.
2). The 24 hour safety checklist folder for PICs had missing documentation for hourly safety checks from January 12-17 between 1am to 6am.
3). The dirty utility room door on the first unit was left wide open during both days of inspection. The sign on the door reads "Please Keep This Door Closed At All Times"
4). It was found that several wound care flowsheet were not being followed up. A discussion with the staff assisting with the inspection found that some wound care protocol was started inappropriately and a education follow up with this staff was scheduled.
Corrective Action(s): Please ensure that all policies and procedures are implemented appropriately by staff.
Date to be Corrected: February 15, 2022
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